Found 10864 matches for
© 2018 selection and editorial matter, Therese Feiler, Joshua Hordern and Andrew Papanikitas; individual chapters, the contributors. Andrew Papanikitas examines healthcare ethics in a healthcare market. He suggests that any form of market presents ethical issues for healthcare professionals - these are issues that are both related and unrelated to the economic drivers of healthcare. These, he suggests, can be framed as a market in healthcare ethics. He discusses current and possible forms of a market in healthcare ethics which serves a wider healthcare sector. A market in healthcare ethics - if it is to effectively serve society - must sustain “everyday” aspects of good healthcare. He argues that, unless it is appropriately resourced, pressures to concentrate on paid activities in a healthcare market will mean that healthcare ethics is shaped by its “purchasers”. For a market in healthcare ethics to work, purchasers must recognise value in ethics activities, and providers must offer products that are meaningful to purchasers. He calls for further research into healthcare ethics as a market.
© 2018 The Author(s). The RCGP conference, like other annual healthcare conferences offers a protected space for reflection on ethical aspects of practice. This paper presents a summary and discussion of a fringe session led by the RCGP Committee On Medical Ethics at the 2017 RCGP annual conference in Liverpool. Well thought-out rules offer a potential solution to the burden of responsibility for making every single decision from first principles. But guidelines can be difficult to follow, too numerous to know, may conflict with each-other and may not be appropriate in all circumstances. Delegates at this meeting discussed barriers to good guideline development and implementation, perceptions of medicolegal risk in non-adherence, aspects of benefit, harm and justice in guideline use and ethical guidelines. Delegates found it easier in the meeting to critique clinical rather than ethical guidelines. There was broad agreement that understanding how to practice in relation to guidelines represented a learning need in general practice education.
Objective: Characterize responses to non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral treatment (ART) initiated during acute HIV infection (AHI). Design: This was a prospective, single-arm evaluation of once-daily, co-formulated emtricitabine/tenofovir/efavirenz initiated during AHI. Methods: The primary endpoint is the proportion of responders with HIV RNA less than 200 copies/ml by week 24. We examined time to viral suppression and CD8 cell activation in relation to baseline participant characteristics. We compared time to viral suppression and viral dynamics using linear mixed-effects models between acutely infected participants and chronically infected controls. Results: Between January 2005 and May 2009, 61 AHI participants were enrolled. Of participants whose enrollment date allowed 24 and 48 weeks of follow-up, 47 of 51 (92%) achieved viral suppression to less than 200 copies/ml by week 24, and 35 of 41 (85.4%) to less than 50 copies/ml by week 48. The median time from ART initiation to suppression below 50 copies/ml was 93 days (range 14-337). Higher HIV RNA levels at ART initiation (P = 0.02), but not time from estimated date of infection to ART initiation (P = 0.86), were associated with longer time to viral suppression. The median baseline frequency of activated CD8CD38HLA-DR T cells was 67% (range 40-95), and was not significantly associated with longer time to viral load suppression (P = 0.15). Viremia declined to less than 50 copies/ml more rapidly in AHI than chronically infected participants. Mixed-model analysis demonstrated similar phase I HIV RNA decay rates between acute and chronically infected participants, and more rapid viral decline in acutely infected participants in phase II. Conclusion: Once-daily emtricitabine/tenofovir/efavirenz initiated during AHI achieves rapid and sustained HIV suppression during this highly infectious period. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Evidence for an increased risk of transmission of simian immunodeficiency virus and malaria in a rhesus macaque coinfection model
In sub-Saharan Africa, HIV-1 infection frequently occurs in the context of other coinfecting pathogens, most importantly, Mycobacterium tuberculosis and malaria parasites. The consequences are often devastating, resulting in enhanced morbidity and mortality. Due to the large number of confounding factors influencing pathogenesis in coinfected people, we sought to develop a nonhuman primate model of simian immunodeficiency virus (SIV)-malaria coinfection. In sub-Saharan Africa, Plasmodium falciparum is the most common malaria parasite and is responsible for most malaria-induced deaths. The simian malaria parasite Plasmodium fragile can induce clinical symptoms, including cerebral malaria in rhesus macaques, that resemble those of P. falciparum infection in humans. Thus, based on the well-characterized rhesus macaque model of SIV infection, this study reports the development of a novel rhesus macaque SIV-P. fragile coinfection model to study human HIV-P. falciparum coinfection. Using this model, we show that coinfection is associated with an increased, although transient, risk of both HIV and malaria transmission. Specifically, SIV-P. fragile coinfected macaques experienced an increase in SIV viremia that was temporarily associated with an increase in potential SIV target cells and systemic immune activation during acute parasitemia. Conversely, primary parasitemia in SIV-P. fragile coinfected animals resulted in higher gametocytemia that subsequently translated into higher oocyst development in mosquitoes. To our knowledge, this is the first animal model able to recapitulate the increased transmission risk of both HIV and malaria in coinfected humans. Therefore, this model could serve as an essential tool to elucidate distinct immunological, virological, and/or parasitological parameters underlying disease exacerbation in HIV-malaria coinfected people. © 2011, American Society for Microbiology.
Objective: We assessed the effect of prenatal and peripartum antibiotics on maternal morbidity and mortality among HIV-infected and uninfected women. Methods: A multicenter trial was conducted at clinical sites in 4 Sub-Saharan African cities: Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. A total of 1558 HIV-infected and 271 uninfected pregnant women who were eligible to receive both the prenatal and peripartum antibiotic/placebo regimens were enrolled. Pregnant women were interviewed at 20-24 weeks of gestation and a physical examination was performed. Women were randomized to receive either antibiotics or placebo. At the 26-30 week visit, participants were given antibiotics or placebo to be taken every 4 hours beginning at the onset of labor and continuing after delivery 3 times a day until a 1-week course was completed. Logistic regression and Cox proportional hazards models were used. Results: There were no significant differences between the antibiotic and placebo groups for medical conditions, obstetric complications, physical examination findings, puerperal sepsis, and death in either the HIV-infected or the uninfected cohort. Conclusion: Administration of study antibiotics during pregnancy had no effect on maternal morbidity and mortality among HIV-infected and uninfected pregnant women. © 2009 International Federation of Gynecology and Obstetrics.
© 2018, © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub–both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into ‘wicked problems’, and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention.
© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ. The House of God is a seminal work of medical satire based on the gruelling internship experiences of Samuel Shem at the Beth Israel Hospital. Thirteen 'Laws' were offered to rationalise the seemingly chaotic patient management and flow. There have been large shifts in the healthcare landscape and practice since, so we consider whether these medical truisms are still applicable to contemporary National Health Service practice and propose updates where necessary: People are sometimes allowed to die. GOMERs (Get Out of My Emergency Room) still go to ground. Master yourself, join the multidisciplinary team. The patient is the one with the disease, but not the only one suffering. Placement (discharge planning) comes first. There is no body cavity that cannot be reached with a gentle arm and good interventional radiologists. Fit the rule to the patient rather than the patient to the rule. They can always pay you less. The only bad admission is a futile one. If you don't take a temperature you can't find a fever and if you are not going to act on it, don't do the test. Show me a BMS (best medical student) who ONLY triples my work, and I'll show you a future Foundation Year 1 doctor (FY1) who is an asset to the firm. Interpret radiology freely, but share your clinical findings with the radiologist and in a timely fashion. Doing nothing can be a viable option. These were developed in conversation with Samuel Shem, who also offers further insight on the creation of the original laws.